As a follow-up to its landmark report, To Err Is Human, the Institute of Medicine has determined that medication errors are a serious public health risk and that the risk remains a widespread and growing threat.

Medication errors result in at least 1.5 million preventable injuries per year, four hundred thousand of which occur in this country’s hospitals. It’s estimated that medication errors add at least $3.5 billion in extra yearly medical costs.

The errors are spread across all age groups, but older adults are the most likely to be hospitalized for medication-related injuries, according to the Food and Drug Administration. It’s been estimated that almost half of these errors occur in those over the age of 60.

That’s not a surprising statistic, considering that older people take more medications on average than other age groups. And, with more medication use, there are more opportunities for mishaps.

Bar coding, not shelving similarly named medications close together, and other mistake-prevention measures go a long way toward eliminating errors. But, although prescriptions are double-checked (and often triple checked), errors still occur.

The most common error resulting in injury is substituting the wrong drug by mistake. Other types of errors include incorrectly interpreting the doctor’s instructions when generating the prescription labels, and dispensing wrong dosages of correct medications.

A recent study of prescription errors found that almost ninety percent of reported mistakes were discovered during medication counseling offered at the prescription counter and were then corrected before a patient left the store. It appears that this one simple action can prevent a large majority of errors from happening.

I think back at how often I’ve been at a prescription counter when a pharmacy clerk asks a customer if he or she would like to talk with a pharmacist about a new medication being picked up. More often than not, the customer refuses the service, presumably because of time constraints.

If pharmacy customers would take a moment to review a new medication with the pharmacist, many errors would be discovered and corrected before a customer leaves the pharmacy. During such a consult, the pharmacist looks at the medication and dosage, and confirms that it’s intended for whatever condition you discussed with your doctor.

Another potential lifesaver is that, when refilling a prescription, take a few moments at the drug counter to open the container and make sure it’s the same medication you usually take. If the medication looks different, don’t assume that it’s merely a different generic brand. Question the difference to confirm that it is the same medication by a different manufacturer.

The most important thing to remember is that all health professionals are human and they can make mistakes when distracted or rushed. We, as patients and customers, must realize that it’s our responsibility to question anything that doesn’t seem or look right to protect our own health and keep preventable errors to a minimum.

Thoughts? Comments? I’d love to hear them!

This year I’m “passing it forward” by ending my blogs with a shout out to some of my writer friends and ask that you take a moment to stop by their blogs and websites also. This week check out:

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About James J. Murray, Fiction Writer

With experience in both pharmaceutical manufacturing and clinical patient management, medications and their impact on one’s quality of life have been my expertise. My secret passion of murder and mayhem, however, is a whole other matter. I’ve always loved reading murder mysteries and thrillers, and longed to weave such tales of my own. Drawing on my clinical expertise as a pharmacist and my infatuation with the lethal effects of drugs, my tales of murder, mayhem and medicine will have you looking over your shoulder and suspicious of anything in your medicine cabinet.

10 Responses to Medication Errors – A Killer

Jim,
Great topic as usual. One very scary sentence is that 90% of reported errors are caught at the pharmacy. While it is wonderful they are being caught, they are being caught because the pharmacist and the patient or whoever is picking up the prescription for the patient is paying attention and asking questions. What percentage of prescription errors are actually reported?

The report you reference indicates that 80% of the reported errors are the wrong drug or the wrong dosage. These would seem, to the interested yet naive observer, to be the two factors most easily avoided. That would also seem to be the obvious issue to attack with vigor.

Sure am glad I work with computers. When I mess up, a reboot usually clears up the problem.

Yes, the most reported errors are for the wrong drug or wrong drug dosage. Unfortunately, humans input the data that the computer spits out for drug dispensing and I suspect that this is where these two errors occur. It’s the same old problem for the healthcare worker : pay attention, pay attention, pay attention, etc…. with the source being distractions, distractions, etc….
That’s no excuse but it’s the reality of the issue.

Very honestly written blog that documents the truth. You have told it, the way that it is.
The patients receiving prescriptions and often times the Pharmacists filling the prescriptions
are distracted with multi-tasking and just too busy to slow down. The statistics speak volumes
with regard to the frequency of occurrence of errors that have life threatening consequences.
From one Pharmacist to another thanks for putting pen to paper.

My elderly father-in-law was mistakenly prescribed coumadin when he entered the nursing home. I don’t know if it was a doctor error or nursing home error, or perhaps the pharmacist misread the doctor’s handwriting, but if my husband hadn’t been monitoring his dad’s medical affairs so closely it could have been a disaster healthwise. Thanks for an important article!

Jim
Whoa! Really sobering and eye-opening blog … like many of the ones that have gone before!
I guess the only “salvation” I find for people like me are the words … “A recent study of prescription errors found that almost ninety percent of reported mistakes were discovered during medication counseling offered at the prescription counter and were then corrected before a patient left the store. It appears that this one simple action can prevent a large majority of errors from happening.” in your blog.

I am glad that I have this “failsafe” … but I also drew a deep breath when in Walt’s earlier response he mentioned someone else picking up my prescriptions … which my wife has done for me often. From now on I am going to ensure that when we do an Rx collection for each other we take that extra precaution and ask!